Print and mail to: WCCRT 205 E Main St. Suite 12, Wautoma, WI 54982

REGISTRATION FORM
NAME

ADDRESS

CITY STATE ZIP

PHONE(      ) -

E-MAIL

Waiver: This Agreement is given below by the undersigned applicant for the benefit of Coordinated Community Response

Team (CCRT) and its respective divisions and association, agents, members, sponsors, promoters, and affiliates. I

Acknowledge that racing is an inherently dangerous sport in which I participate at my own risk and that CCRT and its

associates are a non-profit corporation. In consideration of and as a condition of my participation I individually and on behalf

of my heirs, executors, administrators, legal representatives, successors and assigns, release and forever discharge, hold

harmless, indemnify, including as to attorney fees, and promise not to sue Releases on, from or against, and waive, any claims,

damages, expenses or demands arising directly or indirectly from or attributable in any way to the negligence, action or failure

to act of any Releases in connection with the Bannerman Trail Run, CCRT including travel to and from such event, in which I

may participate as a racer, rider, team member, spectator or in any other manner. Every term and provision in this agreement is

intended to be severable. If any one or more of them is found to be unenforceable or invalid, that shall not affect the other terms

and provisions, which shall remain binding and enforceable. I currently have no known physical or mental condition that would

impair my capability and am fit to fully participate in this competition.

Participants under 18 must have parent or guardian signature

Individual(s) Attending Signature_______________________________________________________________

Circle One:
1 mi. FUN       5K       10K       HM                                                       AGE:_________________   Gender: M / F
         
Shirt Size: Adults:   Sm    Med    Lrg      XL                  Youth: Sm  Med  Large